Team factor
Recommendation
Climate and culture
• More “we” less “me”
• Mutual respect; calm and decisive
• Hierarchy still has a role
• “What” is right, not “who” is right
Establish structure
• Assign roles
• Assign responsibilities
• Establish priorities
• Communicate throughout
Create shared mental model
• Ensure all are on the “same page”
• Invite input when possible
• Outline priorities
• Set emotions of the team
Cross monitor
• Monitor performance
• Monitor workload
• Flatten hierarchy
• Encourage feedback
Maintain resilience
• Routine practice sessions
• Request feedback
• Encourage debriefing
• Provide time for casual interaction
In 1977, the largest aviation disaster (to date) occurred when flights KLM 4805 and Pan Am 1736 collided. Five hundred and eighty-three died. Investigators concluded that not only was the accident wholly preventable, but that a major cause was because the crews had “failed to take the time to become a team” [1]. In a similar vein, evidence shows that fewer planes crash when the copilot is flying [7]. There may be several explanations; however, most believe this is because, firstly, the senior pilot is unafraid to speak up and, secondly, because the subordinate is now actively involved [7]. In other words, an ad hoc team has formed with larger mental and physical capacity than previously existed. Evidence suggests the same for acute care medicine [2]. However, what our profession has been slower to realize is that team skills are not innate and therefore cannot be left to chance. In addition, these are nontechnical skills and require novel approaches such as simulation. As will be outlined, team skills encompass effective communication, adaptability, compensatory behavior, mutual monitoring, and the ability to give and receive feedback [2]. In short, modern trauma care is as much about “team dexterity” (and “verbal dexterity”—see below) as it is about traditional factual knowledge or procedural skills.
In 1935, after the crash of the B17 bomber during a test flight, it was lamented that “the modern plane is just too much for one man to fly” [1]. Similarly, the complexity of trauma care makes the modern patient simply too much for one clinician to manage. In fact, the modern critical care unit patient has been estimated to require approximately 180 steps per day [1]. Regardless of the exact number, clearly such complexity exceeds even the most capable individual. Therefore, it is not hyperbolic to argue that without effective teamwork high-quality trauma care is largely impossible [2].
What Does It Take to Create a Team?
Teamwork, which can be defined as “cooperative efforts to achieve a common goal,” is more than just subordinates doing as the leader tells them [2]. Instead, it is about maximizing the mental and physical problem-solving capabilities, such that the sum exceeds the parts [2]. In addition, task demands (rescuing the patient) and social demands (running the team) have to work in parallel [2, 8]. Expressed another way, we need strategies to turn individuals into team players, or else the team fails and the patient pays the price. Individual team members will not share their abilities unless they feel “safe” to do so [2]. This does not mean that we no longer need leaders and leadership qualities. However, it does mean that we cannot create the teams that we want unless we create the culture that we need [8].
Culture is a complex whole that includes the knowledge, beliefs, customs, and habits possessed by a group. It is a powerful influence upon behaviors, attitudes, and actions [8]. Traditionally, medicine has a laudable culture that includes patient ownership and self-reliance. However, we typically focus on the individual agenda rather than the cohesion of the team [2]. We also presume that success results from individual efforts (and failure from individual shortcomings), rather than advantages proffered by the culture or environment [2]. As a result, quality care has been historically linked to how the solo practitioner performs, and remedies have focused on individual competence [2–6, 9]. This needs to change.
In addition to accepting the need for teamwork, we also need to perfect the team structure. The most common team failings (and therefore the areas on which to focus our resources and energies) are the inability to assign roles and responsibilities, to hold team members to account, to advocate a position or a corrective action, to use checkbacks (i.e., “closed-loop communication”), to seek usable information (as opposed to just “data”), to prioritize tasks, and to cross monitor other team members [2]. In short, a team of experts is not the same as an expert team [2].
Teamwork: Good and Bad
Teamwork is probably the best way to mitigate task overload and fixation errors. However, not all teamwork is inherently good. As a result, psychology also offers useful cautionary tales for the modern physician. Zimbardo’s infamous Stanford prison experiment (which had graduates students assume the roles of prisoners and prison guards) demonstrates how easily we can be made to assume roles even when not beneficial. Even though play acting, the students quickly formed into two teams, with one becoming excessively unruly (the prisoners) and the other excessively sadistic (the guards). In a similar vein, Stanley Milgram’s work (where he was able to get people to administer electric shocks to others) further demonstrates our propensity to blind obedience [10]. Solomon Asch’s experiments (where he could get experts to give incorrect answers just by having other confederates answer incorrectly beforehand) show how easily we can be made to do things that we know are wrong. Of note, in Asch’s experiments there was no overt coercion, merely the power of embarrassment and social conformity [10].
The apparent irrationality of modern man and his (or her) blind spots is tough for some professionals to accept [8]. However, humans have evolved as social beings and are therefore highly susceptible to social pressures [2, 8]. This will be explored in more detail in Chap. 5. Regardless, it should not be surprising that we resort to behaviors that have worked well for most of our evolutionary past, especially during a crisis [8]. Accordingly, good team leaders know to capitalize on the best of our primitive crisis behavior and mitigate against our innate shortcomings. For example, good leaders can capitalize on our propensity to obedience during a crisis. At the same time, good team leaders realize that too much hierarchy will suppress the team’s larger cognitive capacity [8].
Insightful team leaders should know that once a majority of team members have formed an opinion, they usually stick with it despite contradictory information [2]. This is done subconsciously to reduce a sense of isolation and of “cognitive dissonance” (the discomfort that humans have with holding two or more contradictory ideas simultaneously) [10]. As a result, a good team leader will deliberately and routinely challenge assumptions (why are you so certain this is hemorrhagic shock?). In a similar vein, “group think” means that teams may follow the majority opinion rather than the rational argument (“if we all agree, then we can’t be wrong”) [2, 10]. As a result, the good team leader will force the team to seek out contradictory information (“I still want to see that ECG before we take this patient to the operating room”). Interestingly, teams can also amplify individual behavior. For example, groups tend towards greater risk if an individual’s initial tendency was to be risky and towards more caution if individuals were risk averse [2, 10]. Team behavior can (and must) be managed and is a key leadership skill that can be taught.
Team Leadership 101: The Shared Mental Model
Leadership includes providing structure to chaos and organization where previously there was none [8]. A key strategy is the “shared mental model” (a common understanding, or, in colloquial terms, a sense that everyone is “on the same page”) [2]. This helps to form a task-focused (rather than power-focused or ego-focused) team as well as a structure to prioritize duties, manage information, establish roles, stabilize emotions, and build confidence [2]. If time allows, then the team leader should invite members to suggest a mental model (“What do you think? What should we do?”). After all, diverse inputs can provide the team with a more comprehensive view [2, 8]. However, under time pressure, the leader has to rapidly establish a reasonable mental model that members will support (“I believe its hemorrhagic shock; please do the following”) [3]. Studies have shown that the best situational awareness and the shortest reaction time come from practice and prior exposure [8]. As a result, we should look to regular simulation as an important (and safe) team-training tool. In this way, simulation is a great way to develop team “reflexes” and for leaders to learn the power of the “shared mental model.”
The greater the overlap in shared mental models, the more likely that team members will predict, adapt, and coordinate, even if dealing with stress or novelty [2]. It is also essential to regularly update the shared mental model (“okay, the airway is secured; our next priority is…”) and to ensure that it still makes sense as new knowledge comes to light (“I now have an ECG that shows ST elevation—please listen up because things have changed”). Task assignment is usually specified by profession (e.g., anesthetists intubate and surgeons operate) [2]. Therefore this does not usually need to be negotiated in the mental model. However, if there is confusion (i.e., both the anesthetist and surgeon could insert central lines), then the good leader predicts that it may cause confusion and hence that it needs to be explicitly stated (“Dr. Smith, you intubate; Dr. Jones you do lines”). In short, the mental model must be clear, proactive, and flexible (Table 4.2).
Table 4.2
Practical strategies to improve verbal communication in a medical crisis
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